Dental Caries and

Periodontal Diseases
 Caries

The diagnosis of caries is made through a combination of the clinical

examination and radiographs. Unless fairly large, interproximal caries in the
posterior region usually requires radiographs to make a diagnosis.

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Bitewing film is primarily used for caries identification,-
but periapical film is

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also helpful. The difference in angulation between the two films gives two

-
different perspectives and can be especially helpful in diagnosing recurrent
caries around existing restorations.
 Proximal caries susceptible zone

caries

Approximately 40-50% demineralization is required for radiographic

detection of a lesion.
Thickness of the tooth buccolingually masks the carious lesion when
it is small.
The actual depth of penetration of a carious lesion is actually deeper
than it appears on the radiograph.
 Caries

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Bitewing Film primarily

*
Periapical film also used
Low kVp, high contrast
V .

rost
Factors affecting appearance of caries on
-

radiographs
Buccolingual thickness of tooth. The thicker the tooth, the more difficult it
- -
is to see the extent of the caries.
Limitations of 2D film. The extent of carious involvement cannot be seen
-
&
in a buccolingual (cheek to tongue) direction.
X-ray beam angle (horizontal or vertical). This is especially important
when trying to identify recurrent caries, since changes in angulation may
cause- the superimposition of the existing restoration with the carious
lesion. Overlap due to improper horizontal angulation makes it very
difficult to diagnose early interproximal caries.
-
Exposure factors. Caries detection is improved with a lower kVp setting,
which provides a higher contrast. If the overall density of the film is too
light or too dark, the diagnostic potential of the film is limited.

Kup - h!gh controst

Low
-

!
 Caries Classification

I M A
A

I = Incipent
M = Moderate
A = Advanced S
S = Severe
 e
s!b -

Bu dur
o
Staging of Caries on Radiographs
ICDAS

0= no radiolucency 0

-
1= radiolucency in outer ½ of enamel 1 I
-
2= radiolucency in inner ½ of enamel ± DEJ 2-3
dent!n
②
3= radiolucency in outer 1/3 of dentine 3-4 >
-
-
4= radiolucency in middle 1/3 of dentine 3-4
5= radiolucency in-
inner 1/3 of dentine, clinically with cavity 5
6= radiolucency extending to the pulp, clinically with cavity 5-6

ICDAS: International Caries Assessment and Detection System

Interproximal
Caries (Incipient) I

Cone-shaped radiolucent area

Up to half the thickness of enamel.
Usually not restored unless patient has high level
of caries activity (high risk).
Treat with fluoride.
Incipient caries lesion on the mesial of tooth #46 (red arrow)
Incipient caries lesion on the mesial of tooth #36 and distal of
tooth #35 (red arrow)
Interproximal Caries
(Moderate)
M

More than halfway through the

enamel (up to DEJ)
 Moderate caries lesion on the distal of tooth #35 (red arrow)
Incipient caries lesion on the distal of tooth #25, mesial of tooth #26 (black
arrow)
 0

Moderate caries lesion seen on previous radiograph, the mesial of tooth #47
(red arrow)
Moderate caries lesion on the mesial of tooth #43 (red arrow)
Interproximal Caries
(Advanced)

A A

From DEJ to half-way through dentin

Advanced caries lesions identified by red arrows.
Advanced caries lesions seen on previous radiograph.
Advanced caries lesion
Advanced caries lesion
 Incipient caries lesion (white arrow)
S
Moderate caries lesion (pink arrow)
ge Advanced caries lesion (red arrow)
Interproximal
Caries (Severe)
S

More than halfway through the dentin

Of
1 2

ye

Severe lesion (red arrow)

Restorative problems (green arrows) Secondary caries

(1),
Overhanging mangins (2),
Gap under the restoration (3)
 O
Severe lesion
 Transillumination
In the anterior region, interproximal caries can often be diagnosed using

-
transillumination, which involves directing a bright light through the contact areas.
Combining transillumination with radiographs enhances the diagnostic information.

o * frons!llum!nat!on
fl!g
Trod!ography
ht)
 Occlusal Caries

Must have penetrated into dentin

Diagnosed from clinical exam

May be seen as thin radiolucent line or cup-shaped zone

underlying occlusal enamel, but difficult to see on radiographs
unless lesion is large.

Sharp explorer used too forcefully may contribute to spread of

caries by opening up pit or fissure
 Occlusal Caries

The apex of the triangle is toward the outer

surface of the tooth and the base is at the DEJ.
Radiographs are not a reliable diagnostic aid for
the detection of occlusal caries.
Occlusal caries
Occlusal caries
Buccal / Lingual Caries (Black V)

Should be identified from clinical exam.

Sometimes seen as well-defined circular area in

middle of tooth, although it is not very radiolucent.

Depth can not be determined radiographically.

 Lingual caries on tooth #17
(Can’t tell whether it’s buccal or lingual from one radiograph)
 Buccal caries with severe interproximal caries on #44
(Can’t tell whether it’s buccal or lingual from one radiograph)
 Root Caries

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Usually found on older individuals with prominent recession and/or periodontitis.
May have xerostomia due to medications.
May be confused with cervical burnout.
I
Root caries
Root caries
 Cervical Burnout
&
Cervical burnout is an apparent radiolucency found just below the
-
CEJ on the root due to anatomical variation (concave root
formation posteriorly) or a gap between the enamel and-
bone
-
covering
-
the root (anteriorly).
Mimics root caries.
This radiolucency usually disappears when another film of the
region is examined.
Caries does not occur on the root of the tooth unless there is loss
of alveolar bone and gingival tissue due to recession or
periodontitis.
Root caries may be confused with cervical burnout

--
Cervical burnout appears as a collar or wedge-shaped radiolucency on
the mesial and distal root surfaces near the CEJ of a tooth.
The tissue density at the cervical region of the tooth is less than the
regions above and below it. (variable penetration of X-ray)

Burn-Out:
-
•Mainly located at the neck of the tooth (Demarcated above by enamel
cap or restoration and below by the alveolar bone)
•Usually all teeth are affected esp. smaller premolars.
-
&
•It is more obvious when the exposure factors are increased!
 Posterior Cervical Burnout
The invagination of the proximal root surfaces allow more x-
-
rays to pass through this area, resulting in a more radiolucent
appearance on the radiograph.
X-rays directed at a different angle usually pass through more
tooth structure and the radiolucency disappears.
Radiolucency seen at left (arrow) disappears on periapical film of
same tooth. This is cervical burnout.
 Anterior Cervical Burnout

Bone level

Cervical burnout area

The space between the enamel and the bone overlying the tooth
will appear more radiolucent than either the enamel or the bone-
tooth combination.
Cervical burnout in the anterior region due to gap between enamel (red
arrows) and alveolar bone over root (white arrows)
 Recurrent Caries

Found around the margins of existing restorations.

May be due to high caries rate, poor oral hygiene, failure to remove all of the caries
during cavity preparation, a defective restoration or a combination of the above.

Is not always easy to detect radiographically:

1. Location of caries lesion relative to restoration.
2. Angulation of X-ray beam.
Recurrent caries
Recurrent caries
Recurrent caries
 Rampant Caries
Extensive and rapidly progressing caries usually found in children (mostly age of 0-
3) and teens with poor diet and inadequate oral hygiene.

In adults may be seen as a result of cariogenic diet and consumption of too much
sugar.

May be observed in relation to xerostomia following diabetes mellitus and

radiotherapy.
 Radiation Caries

Found in head/neck radiation therapy patients

=
with xerostomia

Fluoride used for control

Before radiation
1 year after radiation
 Mach Band .
bond

amoch
Optical illusion giving appearance of increased radiolucency at the junction
of differing tissue densities, such as -
enamel and
-
dentin.

0
If you block off the enamel with a fingernail, the radiolucency will disappear

=
if due to the mach band effect.
If the radiolucency persists, it may be caries.
 Periodontal Disease
Periodontal ligament attachment and alveolar bony support of
the tooth have been lost.
Junctional epithelium migrates apical to the CEJ.

Bitewings
-
best for diagnosis.
Some feel that paralleling PA’s are best.
-

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Higher kVp recommended (low contrast).
Compare images from different visits (using same technique).
 Limitation of Radiographs
• 2-D representation of a 3-D anatomic structure.
• Superimposition of the bone and tooth structures
• Relationship of hard to soft tissues not evident
• Presence or absence of periodontal pockets.
• Early bone loss (<3mm) is not evident.
• Early furcation involvement is not evident.
• PA: X-ray beam alignment will obliterate the presence of extent of
furcation involvement.
• Facial and lingual aspects of alveolar bone will be superimposed
over the furcation.
 Benefits of Radiographs
Early radiographic changes:
1. Crestal irregularities.
2. Triangulation
3. Interdental septal bone changes
Periodontitis
Involvement:
Localized
Generalized
 Periodontitis
Normal Anatomy:
Alveolar crest corticated
1-1.5 mm from crest to CEJ
Parallel to line between CEJs
Crest is pointed anteriorly
Corticated alveolar crests
CEJ

0.5-2 mm
Alveolar crest more pointed
anteriorly
Contributing Factors
• Occlusal trauma
• Open contacts
• Overhanging, poor contours
• Calculus
• Post-extraction defects
• Systemic involvement (diabetes, blood disorders, hormonal changes, stress,
AIDS)
Horizontal bone loss:
Parallel to line drawn between adjacent CEJs

Vertical (Angular) bone loss:

More bone destruction on interproximal aspect
of one tooth than on the adjacent tooth
 Gingivitis

No bone loss

-
No radiographic signs
 Mild Adult Periodontitis

Loss of cortical density

Rounding off of junction between alveolar

crest and lamina dura

Blunting of crest anteriorly

Mild adult periodontitis
Moderate Adult Periodontitis

Horizontal bone loss or vertical osseous defects

Total extent of bone loss not evident

May have slight mobility

Moderate adult periodontitis

(red arrows point to calculus

Moderate adult periodontitis
 Severe Adult Periodontitis

•Tooth mobility
•Extensive horizontal bone loss or vertical
osseous defects
•Furcation involvement
Severe adult periodontitis
Severe adult periodontitis
 Restorative Materials

•Radiopaque: Structures with higher object density, such as amalgam, gold, silver points, pins,
gutta percha, porcelain.

•Radiolucent: Structures with lower object density, such as older composites and bonding
agents.
Red arrow point to bases
Green arrow indicates recurrent caries with fractured restoration
Composite restoration